Subcortical Vascular Dementia: Case Study

Original Editor - Jonathan Tam, Summmer Bomi Jang, Emily Mulligan, Kiley Praught, Sofia Lamarche, Harrison Mah, Gary Lai as part of the Queen's University Neuromotor Function Project
Top Contributors - Bomi Jang, Jonathan Tam, Kiley Praught, Emily Mulligan, Sofia Lamarche, Uchechukwu Chukwuemeka, Lucinda hampton, Harrison Mah and Koon Kei Gary Lai

Intervention

Our goals for B.B.:

• Improve Berg Balance score to 48/56 in 4 weeks.
• Increase lower extremity manual muscle tests to 4/5 bilaterally in 4 weeks.
• Increase community participation by signing up for weekly tai chi class in 4 weeks.

B.B's. treatment plan

Physical therapy (PT) is indicated in this case. PT has shown to improve or slow loss in mobility, strength, balance and endurance (HELP, (Rolland, 2012)Forbes, et.al, 2014). These improvements correlated to improved functional independence in mobility and ADLs in individuals with dementia (HELP, (Rolland, 2012)(Forbes, et.al, 2014) ). There are no guidelines to best practice and many studies do not state the therapeutic interventions used, however, consistent with general best practice guidelines we will focus on making therapy engaging, functional and task oriented.

In the initial stages, we will do community based physical therapy two times per week focusing on improving functional abilities and balance. The goal of this initial stage is to improve B.B's. functional abilities so they can safely participate in exercise/physical activity outside of the clinic.Intervention plan in this stage will include primarily balance and lower extremity strength training:

• Balance training: 30 seconds twice per day, 3 days per week.
  • Progression from normal stance width → narrow base of support → tandem stance → single leg stance → standing with trunk rotation
  • Balance training will be done on hard surfaces (tile or wood flooring) and transition to soft surfaces (carpet or even standing on a pillow).
  • In clinic we will do perturbation based training. Including tossing/catching a ball and therapist delivered external perturbations.
    • This will only be done in clinic for safety reasons.

• Lower extremity strength training: 10 reps, 2 sets, 2 minutes rest between sets, 2-3 days per week.
  • ¼ squat (be done at a counter or table for balance support if needed)
  • Sit to stand
  • Knee to counters
  • Step ups (beginning with the support of a railing and progressing to without)

Once balance deficits are improved upon, we will drop down to one physical therapy session biweekly to focus on maintaining function and slowing disease progression. At this transition point the patient can transition to exercise in the community. We would prescribe B.B. to engage in physical activity consistent with Canada’s Exercise Guidelines for Older Adults (>65). While the Canadian Alzheimer's Society simply recommends the guidelines for adults, we would use the ones for older adults since they include the addition of weekly balance training (HELP3). These guidelines include:

• 150min moderate to vigorous physical activity, 2 days muscle/bone strengthening exercise per week plus weekly balance training (HELP2).

For aerobic and strengthening exercises, we will implement the use of serious games. Serious games refer to any game thats primary purpose is something other than entertainment. There are many different serious games which have shown to improve physical fitness, functional mobility, strength and balance in older adults (Soares et. al, 2016)(Rossito et. al, 2014). Additionally, they have also been shown to increase exercise compliance in older adults (Rossito et. al, 2014). There are various options available but finding one (or more) that B.B. enjoys is key.

In terms of balance training, we will advise B.B. to sign up for a tai chi class each week. Tai chi has been shown to improve balance, reduce falls and improve quality of life as well as short term cognitive function in dementia patients (Lim et. al, 2019)(Nyman et. al, 2019).

We have chosen to transition B.B. to community based exercise to promote independence and make B.B. a more active member of their community. We have also chosen to keep regular appointments to monitor B.B. as their disease progresses and adjust our treatment plan as needed.

Discussion

B.B. is a 60-year female who was initially diagnosed by a physician with Stage 3 Vascular Dementia Subcortical Subtype (also known as Binswanger’s Disease) and referred to an outpatient neurological rehabilitation centre. She was first admitted to a hospital due to a minor fall 2-weeks ago. Furthermore, it is believed by the PCP that B.B. had suffered a TIA within the past few months but went undiagnosed and untreated. Before present, B.B. was completely independent in all BADLs and IADLs despite living with a sedentary lifestyle and controlled hypertension.

As of late, B.B. has noticed a decrease in her abilities to perform ADLs independently, decreased confidence in balance and strength, and several symptoms of cognitive decline including (but not limited to) memory loss, psychomotor slowness and weakness, and difficulty organizing her thoughts. Although Vascular Dementia is incurable, it would be beneficial for the interprofessional team to manage and prevent complications.

Regarding problems amenable to physical therapy care, it is remarkably important to address B.B.’s lack of confidence in balance by improving balance, strengthening weak muscles that may contribute to impaired balance, and maintaining functional range of motion. Some problems that physiotherapists may not be able to treat but ought to keep in mind include B.B.’s memory impairments, unpredictable changes in mood, behaviour, and personality, and Primary Progressive Aphasia which may cause difficulty communicating with the patient.

Specific to B.B’s treatment plan, the physical therapists will provide her with community-based PT treatment two times per week, primarily focused on improving balance and functional abilities. Following Canada’s Exercise Guidelines for Older Adults (>65), there will be 150 minutes of moderate to vigorous aerobic exercise and two days of strengthening exercises each week in addition to balance training. Strategies employed to improve compliance include the use of serious games and activities that B.B. enjoys such as Tai-Chi.

*talk about pre- and post- outcome measures for this case!*

In conclusion, this case study demonstrates the challenges, impairments, and management interventions that can be used for patients with early stage Subcortical Vascular Dementia. The study also provides evidence of interventions and associated outcome measures that may be beneficial for this population. It is always important to understand problems within the scope of PT practice and when to refer out to other healthcare providers. Lastly, while this case study provides one way of providing treatment to this population, interprofessional teams ought to consider the context of each individual patient and their related goals.

Self-study Questions

1. Which of the following a common symptom in patients with Subcortical Vascular Dementia?

A) Psychomotor slowness 

B) Memory impairments

C) Mood changes 

D) Balance deficits

E) All of the above

2. Based on B.B.’s case, she received a score of 36/56 on the Berg Balance Scale, putting her at risk for falls. In order to improve her balance, what is the best evidence-based intervention that may benefit B.B.’s return to the community?

A) Mental imagery of balancing on one-leg

B) Tai-Chi

C) Tying her lower extremities together to challenge balance with narrower BOS

D) Sitting on a bed with no upper extremity support while the therapist adds external perturbations (e.g. shoves, lean and release, etc.)

3. Which of the following may NOT be an appropriate outcome measure for B.B.’s case in the initial assessment?

A) Community Balance and Mobility Scale (CBMS)

B) Timed Up and Go (TUG) Test

C) Activities-specific Balance Confidence Scale (ABC)

D) 10-metre walk test 

Answers: 1) E 2) B 3) A